Global health

An ophthalmologist remembers his time spent at a mission hospital in Pakistan After September 11, 2001, TV bulletins about attempts to destroy al-Qaeda and the Taliban featured footage of Quetta, a city in Pakistan on the fabled North West Frontier, just south of Afghanistan's Kandahar (see Map in Simpson). The news recalled memories of the weeks I'd spent there, 42 years previously. More came flooding back as I leafed through the pages of my photo album. From Karachi to QuettaAlmost naked, I sweated on a Karachi hotel bed, the ceiling fan spinning above me. What had I let myself in for? Disconsolate, missing my wife and new firstborn son who were already back home in Australia, I could well understand why Somerset Maugham's expatriate Englishmen took to drink in the equatorial Empire. It was the northern spring of 1959, and I was overnighting in Karachi, then Pakistan's capital, en route to Quetta, near the border with Afghanistan. After three and a half years away from Australasia gaining specialist ophthalmic training in England and the USA, I'd allowed an American colleague to entice me to detour on my way home — for a 10-week stint at Quetta's Church Missionary Society Hospital. I hadn't thought of arranging professional indemnity insurance (!), and I'm not even sure travel insurance would have covered all the potential risks. The next morning, I boarded my train to the north. In addition to my ticket, I'd purchased, on advice, my personal air conditioner — a 30kg block of ice in a tin tub placed under my seat for the 24-hour trip. As we journeyed through the Desert of Sind, on the strategic railway built by the British in 1895, stories of the British Raj, India's frontier, the Khyber Pass, the Bengal Lancers and Gunga Din ran through my head. The last remnants of my ice block were melting away as the train chugged up the final slope of the Bolan Pass to enter the Quetta plateau. Missionaries among the militaryThe city of Quetta is a hill-station, about 1700 metres above sea level, in a valley ringed by snowy mountains rising to about 2500 metres. In spring, the valley floor is lush and productive, but the overgrazed hillsides are always bare. The city was rebuilt after being destroyed by earthquake in 1935. Low-rise to the eye, Quetta was, to me, reminiscent of an Australian country town. The population was about 30 000 in winter, doubling in summer. Quetta has long-standing military connections, beginning with its name — derived from "kuwetta", meaning "fort". In the centre of town, on a hillock, is the famed Red Fort antedating British rule. The British arrived in about 1876, encountering tribal groups of Brahuis and Baluchis, as well as the Pathans, the Pashtun nomads. Fearing Russian encroachment via Afghanistan, the British military commanders of the day considered the chain of missionary hospitals positioned along the frontier, including the one at Quetta, to be the equivalent of several battalions. These missions, in effect, garrisoned the border with Afghanistan, supplementing the forts along the thousand miles from Iran to China. During the Second World War, although not an active theatre of war, this garrison town was the second-largest military establishment in the British Empire, after Aldershot. Quetta's military cemetery holds the graves of soldiers from all over the old Empire, from many cultures and religions. In 1959, Quetta still retained the Commonwealth Staff College founded at the height of Empire in 1907. Security was still a concern and became evident to me in a personal way. One day, when I'd cycled out of town to photograph the scenic city and surrounds, two policemen pounced on me and confiscated my camera film — India and Pakistan were already battling over Kashmir and there had been recent bomber activity at the Indo-Pakistan border. Western medical outpostQuetta's mission hospital was originally established in 1886, and had been rebuilt after the earthquake. In the courtyard there were small cottages forming the caravanserai where patients were nursed by relatives who also took care of food and cooking. Throughout the day, electric amplifiers and loudspeakers alerted us to the call of the muezzin, reminding our Christian medical island of the dominant culture that lapped against the walls of the hospital compound. Purdah (seclusion) and veiling were still upheld in Quetta despite its cosmopolitan community. The hospital had a segregated women's section, the zenana wards. The hospital served the city and the region, catering particularly to the trans-border nomadic Pathans who moved down through the Bolan Pass to the southern plains during the winter, returning to the hills of Afghanistan during the summer. Accordingly, these tribal nomads had two opportunities each year to benefit from Western medicine. Cataracts and neglected chronic diseases were common presentations, as was diarrhoea. I myself suffered diarrhoea on several occasions and progressively lost weight during my stay. Faecal tests positive for blood and/or amoebae sentenced one to amoebicides; negatives dictated sulfas, to which my bugs responded. The diarrhoea was surely related to the town's contaminated water supply. Irrigation water from the city's reservoirs flowed through the streets alongside the footpaths. Using removable paddles, the waterman selectively diverted the flow into separate open channels for individual sections of the town on given days. Not surprisingly, the water reaching our vegetable gardens in the hospital compound was murky. This public health issue didn't seem to agitate either the city authorities or, in general, the Western doctors! In winter, the hospital ran an outreach clinic at Shikarpur, 200 miles to the south. Many such clinics, known as "cataract camps", were held on the Indian subcontinent under missionary auspices, foreshadowing the Fred Hollows Foundation. Cataract surgery and other proceduresEvery operation began with a Christian prayer. For the anxious patient, this was extra premedication. Local anaesthesia was used for cataract operations — patients' eyelids were kept open during the procedure with a pair of locally made fork retractors, handheld by the assistant, one of the male nurses trained in the hospital's own program. Graefe section with conjunctival flap was standard, progressing to intracapsular extraction. I carried out over 100 cataract procedures in my 10 weeks, and many plastic operations on eyelids and tear ducts. I treated one patient with retinal detachment. I also assisted at numerous general surgical procedures and outpatient clinics. The hospital's surgeons — Pakistani Christians as well as English — were skilled in all aspects of surgery (ophthalmology included). I saw many cases of advanced cancers of the head and neck such as I'd never before witnessed that were managed with massive excisions and repairs. Radiotherapy was available in the form of radium needles. When two of those valued needles were mislaid, many of the hospital staff devoted the day to search for them — they turned up when an American geologist scanned the rubbish tip with his Geiger counter! A social summerThe social atmosphere throughout my stay was memorable. I was made to feel one of the family by the hospital's director, Dr Ronnie Holland, son of a previous director, Sir Henry Holland, who had been knighted for heroism in the 1935 earthquake. His wife, Joan, was a remarkable woman who, while pregnant, had survived near-fatal polio, being kept alive with manual resuscitation until an iron lung could be procured and repaired. She now worked from her wheelchair, as nurse-anaesthetist. Sunday was a real day of rest, commencing with chapel and then a relaxing picnic lunch on the English lawn of the hospital gardens, next to a rich and varied orchard. It was here that I became partial to green tea. At the Hollands' table, I met intriguing characters from many cultures. They included the indigenous Bishop of Karachi, Chandhu Ray — an amiable man with whom to exchange philosophies; Parsee merchants, who were the first to tell me that their dead were disposed of on special towers, for the vultures; and American scientists working for United Nations agricultural or prospecting agencies. Among other social engagements were invitations to dinner with Australian army officers at the Staff College. When it came time for the Hollands to open the hospital's summer cottage in the hill-station of Ziarat, 70 miles east, and elevated some 900 metres above Quetta, I accompanied them. We set off for the weekend through a narrow defile to a higher plateau before climbing the dusty hills on one side of the broad valley. As I swallowed the dust and, terrified, looked over the rim of the snaky alpine tracks, I was told that Alexander the Great had passed along the valley below after conquering Swat, in the border regions near China. At various points in our passage, we came across clusters of flags on poles like those marking golf holes, but twice as tall — markers of nomad graves. At 630 metres above sea level, juniper trees suddenly appeared on the valley walls, creating a new demarcation line between the bare slopes below and the trees, which only thrived above this height. The mountain air was laden with the scent of thyme, as well as juniper. ReflectionsAt the end of my adventure, returning to my hotel in Karachi, I was surprised to find that Bishop Ray had left a message for me. He invited me to lunch with him, and then came to the airport to see me off. His touching courtesy prompted me to ponder the situation of the Christian minority and its missionary doctors, whose lives I had shared. My missionary friends were not confounded by their inability to care for everyone, everywhere in the region. They were realists, content to do all they could to meet local needs. To them, their calling didn't involve self-sacrifice (although a young English nurse did die suddenly during my visit). Perhaps the missionary urge, previously a preserve of the Christian medical missionaries, can be best illustrated by paraphrasing Sir Henry Holland: Our aim is to care for the whole person, body, mind and spirit. Our healing is like a sermon in the ward. It's not bait to lure the people. It's delivered in dedication to our calling, undaunted by dangers and difficulties. Today, the North West Frontier is an even more dangerous place than it was in 1959. Opposition to the presence, and even to the work, of medical missionaries has intensified. I reflected on what the hospital and I had provided for each other. I'd assisted slightly with the patient load. Quetta gave me the benefits of concentrated experience with advanced, neglected, untreated disease; further medical and surgical insight; and the privilege of working with admirable colleagues dedicated to the impressive people native to this frontier. I'd learnt much more in Quetta than surgery alone.

Ivan Cher FRACS

An elective term in Malawi inspired students to make a difference in medical aid. When, at the end of 2000, medical students Greg Fox and Greg Moloney travelled from the University of New South Wales (UNSW) to Blantyre, Malawi, Africa, to complete an elective term at Queen Elizabeth Central Hospital, they witnessed a health system drastically hampered by a shortage of medical resources. On return to Australia, they resolved to "give back" to those in the developing world who had taught and welcomed them so generously. With the support of other UNSW medical students, the Medical Students' Aid Project (MSAP) was born. Our non-profit, student-run, volunteer organisation is the first of its kind in Australia. Our primary goal is to deliver targeted medical aid to hospitals in developing countries. Working in the children's ward we realised what a huge difference some basic items such as cannulas, needles and emergency equipment would make to the doctors' ability to care for sick children. The health problems facing these countries are not simple, but we believe that many individual contributions can together make a difference — Greg Fox (left) and Greg Moloney MSAP co-founders. IdealsMSAP tries to ensure that all aid is appropriate and beneficial to our partner hospitals. We do so by delivering only aid that is specifically requested by recipient hospitals. At the beginning of each year, our partner hospitals submit a prioritised wishlist for medical aid, which we use to direct our efforts in fundraising and equipment seeking. MSAP student volunteers visit partner hospitals each year as part of their final-year elective term. Their visits are timed to coincide with the arrival of aid, to ensure it is used appropriately. The hospital wishlists are refined through first-hand feedback during these visits. Forming long-term, sustainable partnerships with the partner hospitals enhances MSAP's effectiveness. Donating to the same hospitals each year ensures that lessons learned from previous years can be used to better meet our goals in the future. Partner hospitals share a number of qualities: they have a need for aid that may be met by MSAP; they provide valuable experience of medical practice in the developing world; and they are in locations that will continue to attract medical students in the future. In return for our efforts, our visits to partner hospitals enrich us with a vivid cultural and educational experience, the memories of which we carry back to share with fellow students and the wider community. Partner hospitalsThe MSAP partner hospitals in 2001 were in Malawi (Box 1), Samoa (Box 2), Tonga (Box 3) and India (the Lady Willingdon Hospital in Manali). Korle-bu Hospital, in Accra, Ghana, has been included in 2002 and has already received a paediatric cystoscope (worth over $5000), and diathermy and laparoscopic equipment. Smaller donations of equipment and medication will also be made to Gizo Hospital in the Western Province of the Solomon Islands and Hospital Santa Barbara in Sucre, Bolivia. "As a MSAP volunteer, I have become aware of the stark contrast between the First World ideals of sterile operating theatres and universal vaccination and the developing world reality of overcrowded clinics and inadequate resources. It is satisfying to have made a small contribution towards bringing the two worlds closer. MSAP has been an important part of my medical education." — Asif Saber, MSAP member How MSAP worksMSAP is entirely student administered and receives generous support from the UNSW Faculty of Medicine and the UNSW Foundation. All MSAP members volunteer their time and the university covers our administration costs. About 20 medical students were involved in 2001 and 2002. Our current patron, Dr Gaye Casper (Senior Conjoint Lecturer, School of Women's and Children's Health, UNSW), provides moral support and practical advice to the students. MSAP collects tax-deductible monetary donations from private and corporate sources. Monetary donations are used to purchase equipment and to fund transportation. Donations of basic and specialised medical equipment are received primarily from Area Health Services in New South Wales. Other sources include private donors, such as retired doctors, medical companies and volunteer organisations such as Global Medical Support (which sends medical supplies to countries in need). MSAP purchases subsidised and in-date medication through Overseas Pharmaceutical Aid for Life (OPAL) (http://www.opal.org.au), a South Australian company that supplies pharmaceuticals to developing countries in accordance with WHO Guidelines for Drug Donations (http://whqlibdoc.who.int/hq/1999/WHO_EDM_PAR_99.4.pdf, link updated Nov 2005). OPAL puts together medication packages, organises customs documentation and arranges commercial delivery or delivery by MSAP volunteers. All equipment collected by MSAP is stored free-of-charge at a Waverley Council depot in Sydney. Towards the end of the year we organise "packing days" to sort equipment onto pallets for shipment to each hospital. Five pallets of equipment were sent overseas in 2001 and in 2002 we expect to deliver five more. "Throughout Australia, large quantities of medical equipment — such as superseded anaesthetic equipment, ECG machines and glucometers — lie in storage and are desperately needed in developing countries" — Peter Fox, MSAP volunteer So far, medical equipment has been transported by commercial shipping lines at MSAP's expense. Members have also carried small quantities of equipment with them when visiting partner hospitals. Free transportation to Tonga in 2002 has been negotiated through the Tongan Consulate General in Australia and the Pacific Forum Line. In two years MSAP has delivered over $100 000 worth of medical aid. The community role of MSAPMSAP is active in international health education for other medical students through lectures, "Developing World Health" night and contributions to student publications. MSAP also contributes to wider UNSW campus activities, for example through our involvement with Anti-Poverty Week. Our annual "MSAP Benefit Night" increases awareness of our cause, raises funds and gives us a chance to thank donors for their generosity. Updates, our newsletter, communicates activities and news to followers. The futureIn just two years, we have received enormous support from the medical profession and the broader community. With ongoing assistance we will continue to expand as an organisation and maintain our capacity to deliver medical aid to the developing world. MSAP has inspired considerable interest among medical students from other Australian universities, who are eager to establish similar ventures. We hope to share our experiences and encourage others to adopt an active role in developing world health. 1: Queen Elizabeth Central Hospital, Blantyre, Malawi MSAP donations 2001: Equipment with a paediatric focus (eg, cephalosporin antibiotics, high-kilojoule powder, paediatric nasogastric tubes and textbooks). 2002: Medications worth $2500 (mainly antibiotics), urine dipsticks, psychiatry textbooks. No pallets sent this year (too expensive). We spent two months studying paediatrics at this tertiary referral hospital towards the end of 2001. The cases we saw were sometimes novel, sometimes gratifying and sometimes heartbreaking. HIV is having a devastating effect in Africa, while conditions such as meningitis, malaria, tuberculosis and malnutrition, readily treatable in Australia, are moving beyond the capacity of the systems attempting to cope with them. One afternoon we basked in a golden sunset by the serene lake shore as fishermen in dugout canoes repaired their nets and infants cavorted in the waters. We'd just finished a long afternoon's clinic where one young man with advanced AIDS sought treatment for painful, widespread shingles; a stooped old lady who had lost all her family wanted relief for her chronic back pain; and a younger widow needed to go to hospital immediately for a renal infection but couldn't afford the dollar to get her there. At least we could help her. Through MSAP, I know that we have made a small but undeniable difference to the patients we met, who first became real and then became our friends. Rebecca Blake, Toby Winton-Brown Women and children fetching water from the village pump. 2: Tupua Tamasese Meaole Hospital, Apia, Samoa MSAP donations 2001: Syringes, gloves, defibrillator, textbooks. 2002: New ECG machine, 1 pallet of equipment (nebuliser, glucometers, ophthalmoscope/otoscope, stethoscopes, anaesthetic equipment, sutures, catheters, stoma-related products). At the end of 2001, I had the privilege of spending two months working in the emergency department of this tertiary referral hospital. Hundreds of patients would queue each day with complaints that would be easy to address in Australia but impossible to treat locally given the lack of basic medications. I will always remember the young patient who sat, seemingly forever, on the surgical ward awaiting an amputation, as his leg infection could not otherwise be treated. The most rewarding part of my time in Samoa was being able to give something back to the community through the MSAP donations. It was overwhelming to see how grateful the people were for these basic medications and equipment. Cath Tacon MSAP volunteer Cath Tacon handing supplies to Dr Satu Viali. 3: Vaiola Hospital, Nuku'alofa, Tonga MSAP donations 2001: Syringes, bandages, sutures, surgical forceps, operating microscope, hysteroscopy and laparoscopy equipment. 2002: Three pallets with similar supplies to those sent in 2001; medications worth $2000 (mainly cephalosporin antibiotics); cardiotocography machine. Throughout 2001, members of MSAP put an enormous amount of energy into collecting and transporting equipment for the Polynesian kingdom of Tonga. Being our inaugural year we had no way of knowing exactly what to expect or how our donation would be received, but my anxieties were allayed the moment I stepped off the plane by the warm welcome I received. The arrival of medical equipment at Vaiola Hospital, a tertiary referral hospital, was greeted with great excitement and thanks. One of the antibiotics was used almost immediately to treat a man with several resistant infections. The equipment "handing over" ceremony was reported by the local newspaper and even made the Tongan Nightly News! Sarah Woodgate MSAP supplies outside Vaiola Hospital, Tonga.

Angus G Ritchie · Adrian T Fung · Peter N Fox · Kathryn E Roberts · John S Vedelago · Rebecca C Blake · Asif A Saber · Jess M Glass · Linda K Martin

More patients than beds. Dr Lion, Dr Kimborarith and Dr Thaly doing ward rounds on the verandah of the Takeo Eye Hospital. Bombed in secret for years by the United States during the Vietnam War, overrun by Pol Pot and his murderous Khmer Rouge, invaded by Vietnam in 1978, blighted by landmines, and lurching through periods of famine, post-colonial political crisis, and intermittent civil war, Cambodia has suffered terribly. Its people are among the poorest in Asia. Aid work commenced by the Maryknoll organisation in 1993 has expanded and been handed over to another Catholic charity, Caritas, supported by funding from Germany and Australia. The centrepiece of the project is an eye hospital in Takeo, 80 km south of the capital, Phnom Penh. Here, services are provided to the poor and local doctors and nurses are trained in the basics of ophthalmology. This is the story of my short time working at Takeo Eye Hospital around Christmas 2001: a day in the life of a volunteer. You can tell that French colonialists were in Cambodia; the bread is excellent and a breakfast favourite at the Café Chisor where I start the day. I hail a prowling motorscooter, because taxis do not exist, and negotiate a price to the Takeo Eye Hospital on the outskirts of this small town. As we bounce and weave along the dilapidated dirt tracks that pass for roads, I notice some causes of the eye trauma that will present to hospital today. Workers threshing rice by hand or angle-grinding in metal shops have no eye protection. Despite the dust and insects, none of the "moto" riders wear goggles, let alone a helmet. The hospital is run by a Dutch ophthalmologist, Dr Franz Lion, and staffed by his three trainees, Dr Eng Kimborarith, Dr Sok Chenda and Dr Poch Thaly, who have come from various distant provinces, leaving their families behind, to attend the 18-month Basic Eye Doctor course. In the high humidity and with a lack of basic hygiene, many injuries from foreign bodies result in corneal ulcers. Pathology services are virtually non-existent and mixed infections are the norm anyway, so ulcers are treated with a combination of antifungals, antibiotics and antivirals. Our day begins with a ward round before 8 am, but the nurses start much earlier, removing dressings and ensuring that the patients' relatives are out of the wards. There are two rooms, each with about 20 wooden platforms making the 40 hospital beds. These are rarely sufficient, and today we have an additional 20 patients who have spent the night on the verandah. Our procession enters each area in turn, led by Dr Lion and his cheery salutation of "Sua s'dei" (an informal "hello"). The patients return the greeting and offer the traditional hands-together gesture of Buddhist greeting. One elderly lady just claps. Brief examinations are undertaken and results of the previous day's surgery are revealed. Patients with corneal ulcers are quarantined in their own ward and it too is full. Carers, who spent the night on the floor beside their relatives, are cooking breakfasts over the fires in the communal kitchen area outside the wards. Other nurses are already assessing new patients, some of whom have travelled great distances and have queued since dawn. To ensure the afternoon's surgery will start on time, nurses will only accept new patients until mid-morning. We join them in the outpatients area; a large room with four small desks, slit-lamps and a few tables for simple procedures. The verandahs are used for assessments of visual acuity, visual fields, eye movements and other basics. A toddler is brought in by her father with a lacerated cornea. Like many locals, he traps wild birds and keeps them at home before slaughter or sale. She has been pecked in the eye and, incredibly, is the third such young patient this week. The injury occurred about a week ago and precious time (and money) has been wasted on "traditional healers" in the interim. She will be properly assessed under anaesthesia this afternoon. A stork tethered outside a Cambodian business. Trapping wild birds for food or sale is common. In my time at Takeo Eye Hospital, I saw three children with eye injuries from being pecked by trapped birds. Another child is screaming inconsolably. He is found to have a small rice grain in the upper conjunctival fornix. I imagine that in future he will not stand so close as his parents bash rice sheaves against the threshing boards. I'm obtaining valuable experience with the slit-lamp in reviewing some of the long-term ulcer patients, but their progress is sometimes discouraging. Every surgery list includes eviscerations of eyes that cannot be saved. One of my patients today is a 10-year-old girl with the classic Khmer smile that the guide books always mention. I've never found out how she lost her left eye; I'm just worried about the persistent ulcer on the right that has her vision down to "count fingers at two metres". Uveitis is a common and painful condition in this community, but in the harvest season only very serious ailments will cause an adult to leave their fields. Advanced cases of uveitis with bizarrely misshapen irides due to lens adhesions are frequent. A steady stream of elderly patients present with glaucoma and cataracts. Lunch is an event I've been enjoying with the local doctors for a few weeks now. One of the cleaners is given funds and goes to the market daily. She returns to prepare delicious traditional meals; like the spicy soup, curried fish, and pickled vegetables which we eat noisily and with gusto, as is the custom. I'm told this feast is only "simple food". It costs me two dollars but that is the daily wage in Cambodia. Everyone who survived the Khmer Rouge has a story, and now that I know them better the trainees are talking about some of these events. Dr Thaly's family were separated to work on different communes for almost the entire four years of Pol Pot's regime. All educated people were considered counter-revolutionaries. Dr Thaly confirms that people were killed simply because they did not have the calloused hands of a peasant, as depicted in The Killing Fields. One doctor in a nearby town survived by passing himself off as mentally handicapped, feigning a twitch and a stammer for four years, and is now unable to cease these behaviours. The afternoons are dedicated to surgery. The operating theatre is airconditioned, but a wardsman armed with a flyswatter watches for intruding insects. Equipment is basic; fragments of razor blades serve as scalpels and haemostasis is achieved with a probe heated in a candle. Adult patients are given a face block and walk in and out of the surgery. Children are anaesthetised with ketamine, and vital functions are monitored by a stethoscope. The eye of our bird-peck girl collapses as the wound is explored and another evisceration is performed. But there are many successful outcomes: tarsal plate rotations for trachoma, trabeculectomy for glaucoma (drugs are unaffordable), lid elevations for ptosis, corrections for strabismus, pterygia removed, and sight restored for many patients by cataract extractions. Last year, this hospital performed 3100 operations. Surgery at Takeo Eye Hospital: barefooted patients and doctors in thongs. In the late afternoon, Dr Lion enthusiastically summons us for a tutorial. Afterwards, I stay back to do some study, but mostly chat, with the trainees. Later, as I'm walking home two nurses on a moto stop and offer a lift. As three is only half the maximum number that I've seen on a Cambodian motorscooter, I feel quite secure. The best place for dinner is back at Café Chisor. This was set up by Dr Lion's wife as a non-profit enterprise to provide employment and training for local women. The food is traditional, wonderful and very affordable, but I have been startled by a scorpion and a snake during meals here, much to the amusement of local patrons. Very few westerners visit Takeo and young Khmers are desperate to learn English, so I am quite popular. I've started giving impromptu lessons to relatives of the cafe's staff and they return the favour in kind. We often end up just laughing at each other. As I return to my room, extinguish the candle (the electricity has failed again) and carefully slither under the mosquito net, I'm very grateful to have learned from the inspirational Dr Lion and other staff, and to have been of some assistance to the needy patients of Takeo Eye Hospital. I hope that this project will one day mean that there are enough Cambodian eye doctors to go around.

Leo J Ryan LLB(Hons), BSc

For theatre staff, the most precious drug in Buka. When the theatre drug safe has nothing in it bar a packet of tea, you know you are in an unusual operating theatre. When I volunteered for a fortnight in October 2001 with AusAID in Bougainville, which lies between the Papua New Guinea mainland and the Solomon Islands, I knew I'd have to resurrect my Third World anaesthesia skills. One can come to terms with halothane anaesthetics and a single syringe — the real test is the tea in the drug safe. For the record, that packet of tea made the best "cuppa" I'd had in a long time. You put several spoonfuls of tea into a strainer and run hot water from the urn through the strainer until your cup has the desired strength. Two tablespoons lasted all day. It worked — thus passing the acid test of all Third World medicine. Faced with a 13-month-old little boy up for three hours of bilateral talipes surgery, I racked my brains: what was the best way to gas him? First World anaesthesia was precluded by the absence of any endotracheal tubes smaller than 5 mm. Anyway, the ventilator didn't work. So I gave the kiddie a knockout premed and snuck up on him with the halothane. Just a few seconds before his Mum and I fell asleep the kid succumbed and I stuck in a laryngeal mask. He breathed himself to sleep for three hours and the surgeon had no complaints. It's a bit like the old air force adage, "Any landing you walk away from is a good landing". Over the years, I've done lots of tours of "good works" — from trips with the Flying Obstetric Service out of Roma, Queensland (about 500 km west of Brisbane), to those with the Forward Surgical Troop with INTERFET in East Timor in 1999. Nothing has given me the satisfaction of "a job well done" as much as this AusAID tour, and I recommend it to others unreservedly. Our orthopaedic team left Buka knowing there were half a dozen kids walking around the place who couldn't otherwise have done so. How does that compare with the list of arthroscopies that is my usual bread-and-butter? Back of BukaThe Bougainvilleans are trying desperately to put behind them the '89 to '99 "crisis" — their term — when a move to secession left a potentially well-off country devastated by war and pollution (eg, from heavy metal run-off from abandoned mines). Conversations with the intelligentsia left me with the distinct feeling that their support lay with the Bougainville Revolutionary Army (BRA), although they would never admit it, and any conversation on the topic is conducted sotto voce. I was one of a four-man team of orthopaedic specialists who, since the peace treaty of 1999 and supported by AusAID in partnership with the Royal Australasian College of Surgeons, have made an annual trek to Bougainville. Airfares and accommodation organised for us, we arrived without a hitch on Buka, the northernmost of the two main islands of Bougainville. First, we had to separate the "VIPs" from the deserving cases. The surgeon had been here before — indeed, his father was a much-respected "expat" from the days before the crisis — and knew that the first patients to be seen in outpatients would be the important people in the village. The trick is to admit that they need surgery but put them off until the real work is done. We did this very effectively, finishing our 25 cases of the visit with three arthroscopies of knees (the postmaster, the bank manager, and the police chief). Interestingly, from a professional point of view, these last three patients had more postoperative pain than that experienced by all the (far more serious) cases put together. Education is obviously related to pain perception. We were accommodated in a hotel at the opposite end of the village from the hospital. Getting from one to the other involved a long and sweaty walk each morning and evening, sometimes in the dark. A throwaway remark, by a fellow guest and expat, put things in perspective. When we asked whether the locals would harm us, he replied that they would rob us, but they wouldn't kill us or rape us (one of our team was a theatre sister) and, if they did, the village would be pretty cheesed off about it and would probably exercise payback on the perpetrators. When AusAID teams weren't in Buka anaesthesia was reduced to its true role in the spectrum of medicine and was provided, perfectly adequately, by two "technical officers", who, as far as I could see, had been trained in the "recipe technique" (eg, "give two inches of the big syringe and about half of the little syringe"). They provided a service that would be envied in many Australian public hospitals: they never argued with the surgeon, and nine times out of ten the patient went to sleep on demand and woke up afterwards. I discovered — the hard way — that a speedy recovery phase was in your own interest, as you recovered your own patients. If you weren't careful, then, when everyone else was drinking tea, you were still applying jaw support. Our team of four knitted together quite quickly. Sister Mary-Lou — whose name, along with those of all the others in this story, has been changed . . . to protect me! — had never done anything like this before. She worked her feet off for 10 days but gave away her Third World inexperience by expressing disappointment when she found out that the only chemist's shop for a thousand miles did not stock self-tanning lotion, this amidst the second-blackest people on earth after Ugandans. She also let it slip, at the end of the trip, that probably nothing we used was truly sterile, as all the bundles were coming out of the steriliser still wet. If she'd told us this at the beginning, we would probably have gone home, but after two weeks we'd adopted a Bukanian attitude to sterility (ie, near enough is good enough). After all, if one can be "a little bit pregnant" then there's nothing wrong with "nearly sterile". A senior orthopaedic registrar joined us for part of the trip; an excellent fellow who worked very hard, saw things he'd only read about, and was imbued with the concept of pro bono work. The resident doctors, nurses and other staff at the hospital were extremely hospitable to us, and my expressed interest in fly-fishing was rewarded with a social outing in one of the locally built "banana boats" — twenty-three feet of unbreakable fibreglass, with a seriously large outboard. However, as these men fished for the table rather than sport, I felt they found my efforts with a fly rod and "feathers-for-bait" amusing and inconsequential but were too polite to say so. Out and about in ArawaWe spent the weekend in Arawa, the old provincial capital; getting there involved a painful 4-hour trip over dirt roads and tracks in a 4WD "troop carrier". Arawa is now a burnt-out shell after the BRA razed it to the ground in 1989. However, a new hospital has arisen from the ashes thanks to Australian aid and, at the time of our visit, had been open for only six weeks. It had a staff of two: an Australian doctor, only four years out, and a nurse from New Zealand. The doctor was away in the highlands seeing patients, but had already done a laparotomy for stab wounds and a caesar. I read, with morbid fascination, his guide to anaesthesia that was pinned to the wall of the theatre. It enumerates a Plan A, then a Plan B (both simply lists drug doses and techniques for giving a very basic anaesthetic). For Plan C, it simply says: "There is no Plan C". We shared accommodation (with hot showers) with several Kiwi policemen, who were there under an NZAid plan to set up an impartial police force. One of them, a young sergeant, described all the expats in Bougainville as either "mercenaries or misfits". Mature consideration revealed that, on social contact thus far, he was probably correct. However, we couldn't decide which group we fell into — one term was as pejorative as the other. Interestingly, several of the locals we met changed their attitude towards us when they clarified that we were not paid for our efforts and were not affiliated to any religious organisation (unless the RACS considers itself as such?). Tom, the Buka hospital carpenter, had accompanied us to Arawa. He had offered his services as a guide and general factotum, having said that his family came from this area and that he would like to visit them. Over the weekend, it became clear that our friend and ever-helpful guide was actually persona non grata in the area over a past relationship involving the daughter of a prominent local leader. Notwithstanding this social drama, Tom felt himself truly to be part of the team, joining the ward round of all the local "orthopaedic" patients rounded up for us to see during our visit. I might add, as a mere anaesthetist, that I thought his contribution to management was at least as sensible as the experts', and probably took more note of local exigencies. I've always maintained that orthopods were just carpenters with chrome-plated tools. The most threatening few moments of my trip actually happened in Arawa rather than Buka, when the "Team Leader" (his words, not mine) Dr Bones sent me off to find beer to sustain us over our weekend there. Tom established that it wasn't available legally. But, he had an address. We set off in the ambulance with Sister Mary-Lou riding shotgun and soon found ourselves in a back street with unnumbered houses. Tom disappeared, coming back with the going price (remarkably reasonable in the circumstances). Then it was my turn to enter the house, without Tom but with 60 kina and a tachycardia. It did cross my mind that the speech of the locals involved in the transaction sounded unusually Australian, but at the time I was more involved in getting out with a case of local beer and both legs working. Back in Buka, I learnt that these locals were the sons of a Buka nurse who had given up everything to educate her boys in Australia. I was quite proud to think that an Aussie education had given these lads an honourable profession. If you have a few weeks on your hands and can't stand the prospect of spending it on the links or the harbour, give a thought to volunteering your services to AusAid. It will not only broaden your horizons but also "reset your thermostat" as far as the truly important things in life are concerned. Now that I've retired from the black art of anaesthesia, these trips are the only thing I miss about "my old life".

Douglas N Gow

Malaria remains a global crisis that kills at least one to two million people per year, mainly children in sub-Saharan Africa.1 Forty per cent of the world's population is at risk of malaria, and each year more than 300 million people have episodes of acute malaria. In recent times, there has been a breakdown in malaria control programs. This has been caused by failure of health systems in the poorest countries, as well as the emergence of mosquitoes resistant to insecticides and malaria parasites resistant to cheap, widely available drugs. In addition, population movements, large-scale development projects, civil wars and conflicts, as well as environmental changes, have all acted in concert to increase the number of individuals at risk of malaria. In Papua New Guinea, for example, malaria is the commonest cause of outpatient presentation and accounts for an estimated 27% of all attendances at health facilities.2 In some Papua New Guinea provinces, malaria is the reason for more than 40% of health centre attendances, and equals pneumonia as a primary cause of death.2 In recognition of the need for a renewed attack on malaria, a global strategy for malaria control was presented to a World Health Organization Conference of Health Ministers in 1992.3 The strategy, now incorporated into the Roll Back Malaria Campaign, promoted a new philosophy emphasising malaria control (in contrast to eradication), and acknowledging the need for different approaches to disease control in different populations. For example, the approach to malaria control in children and pregnant women in Africa is different to that in adult refugee populations. The strategy emphasised the importance of political commitment, such as that given by the heads of State and governments of African countries in Nigeria in 2000 (the Abuja Declaration).4 All participants resolved to commit to an intensive effort to reduce the burden of malaria by strengthening health systems, implementing action plans, improving local capacity, promoting early recognition and treatment of clinical malaria, and reinforcing efficacious preventive measures such as the use of impregnated bednets and chemoprophylaxis. An important component of the strategy is the development of new antimalarial drugs and vaccines. Vaccines have been shown to be one of medicine's most cost-effective interventions. A malaria vaccine that protects for one to five years with 50% efficacy could substantially reduce all-cause child mortality in endemic areas. The cost of such an intervention compares very well with that of using insecticide-treated bednets, and is likely to have major economic as well as social benefits for the populations currently threatened by malaria. An "experiment of nature" suggests that developing a vaccine should be possible. Although many children die of malaria, the majority survive the life-threatening risk of the first few years of exposure and develop clinical immunity. Provided they continue to be exposed to malaria, this immunity protects them from severe disease for the rest of their lives, except during pregnancy. Unfortunately, the immune response that correlates with protection in these lifelong residents of endemic areas has not been identified, so development of a vaccine that mimics this immunity will be difficult. Moreover, malarial parasites demonstrate extreme antigenic diversity. Recent developments, including better methods for antigen production, improved adjuvants and novel delivery systems, provide optimism that sustained and appropriate long-lived immunity can be achieved. Vaccines could be directed against the sporozoite stage of the malaria parasite to prevent infection, or against the stages in human blood — the asexual stage to prevent clinical disease, or the sexual stage to prevent transmission. The malaria vaccine which has been studied in most detail is designed to induce immunity to the sporozoite and the infected liver cell (ie, to stop sporozoites invading liver cells and to kill sporozoite-infected liver cells). In early studies it was shown to induce protective immunity against experimental challenge.5 Under conditions of natural exposure (in semi-immune adult men in The Gambia),6 the vaccine was shown to be safe and well tolerated, with an estimated efficacy (decrease in malaria infection) of 70% in the first nine weeks of follow-up. However, over the 15 weeks of observation, the efficacy fell to 34%. Further trials will determine whether improved efficacy can be achieved in young children. Australian research efforts have led to a multicomponent recombinant protein vaccine targeting the asexual blood stages. This vaccine was tested recently by the Papua New Guinea Institute of Medical Research and its collaborators. The vaccine caused a 62% reduction in parasite density in children, without any harmful side effects.7 Further development will be necessary to produce a vaccine sufficiently efficacious for routine use. In the past there has been a serious lack of funding for research into malaria, partly because companies engaging in this type of research did not expect it to be profitable. A major change has occurred of late, with increased funding from the Wellcome Trust in the United Kingdom, and from the United States through the National Institutes of Health. A grant from the Bill and Melinda Gates Foundation has funded the Malaria Vaccine Initiative of the Program for Appropriate Technology in Health (PATH) (http://www.malariavaccine.org). This worldwide initiative has the specific goal of enhancing the transition of the many promising candidate vaccines from the laboratory to "proof of principle" research in phase I clinical trials. It has funded Australian projects developing vaccines from asexual stage (merozoite) antigens by researchers at Monash University, La Trobe University and the Queensland Institute for Medical Research, partnered by Biotech Australia (New South Wales), the Cooperative Research Centre for Vaccine Technology (Queensland) and Progen Industries Limited (Queensland).8 There are still many challenges in developing a malaria vaccine, such as the need to cope with diverse antigenic types and the importance of stimulating a lifelong response that is boosted by natural infection. Vaccine-induced sterilising immunity that is not boosted by exposure to malaria could put an individual at increased risk when the vaccine-induced immunity wanes. Most importantly, we need vaccines that can be incorporated into national immunisation programs as part of a coordinated, holistic approach to malaria control. Research to find new methods for vector control and new drugs must also continue, as we know from past antimalarial campaigns that a single technology will not be sufficient to control this devastating disease.

Graham V Brown PhD, FRACP · John C Reeder PhD

Conference Report XIII International AIDS Conference, Durban, 9-14 July, 2000 Nelson Mandela argues for urgent action against HIV in Africa John B Ziegler and Rosemary A Ffrench Let us not equivocate: a tragedy of unprecedented proportions is unfolding in Africa. AIDS today in Africa is claiming more lives than the sum total of all wars, famines and floods, and the ravages of such deadly diseases as malaria . . . Economic growth is being undermined and scarce development resources have to be diverted to deal with the consequences of the pandemic . . . Decades have been chopped from life expectancy and young child mortality is expected to more than double in the most severely affected countries of Africa. AIDS is clearly a disaster, effectively wiping out the development gains of the past decades and sabotaging the future. Earlier this week we were shocked to learn that within South Africa one in two, that is half, of our young people will die of AIDS. The most frightening thing is that all of these infections, which statistics tell us about, and the attendant human suffering, could have been, can be, prevented. Something must be done as a matter of the greatest urgency. And with nearly two decades of dealing with the epidemic, we now do have some experience of what works.-- Nelson Mandela1 MJA 2000; 173: 572-574 Prevention - Mother-to-child transmission - Vaccines - Treatment strategies - Hope - References - Authors' details Box 1: HIV in African countries, 1999 Box 2: Trends in mortality among children under five Nelson Mandela's closing address to the conference1 was a welcome contrast to the opening address by Thabo Mbeki, President of South Africa, who disappointed delegates by failing to resolve their concerns about his view that HIV does not cause AIDS. In his plenary address, David Ho (Director, Aaron Diamond AIDS Research Center, New York) noted that Mbeki would be judged harshly by history. Judge Ed Cameron, a gay white South African living with HIV, in a moving address, pointed out that his government had consistently mismanaged the epidemic, and that he was only alive because his income allowed him to purchase antiviral drugs not available to most South Africans with AIDS. Prevention Box 3: Probability of a Zimbabwean boy aged 15 dying before age 50 Box 4: Projected population structure, Botswana 2020 While news of the explosive spread of HIV in the Republic of South Africa highlighted the urgency of effective preventive strategies, there was relatively good news from some countries where decisive action by pragmatic governments was paying off: the HIV infection rate has stabilised at a relatively low level in Senegal; Uganda has brought its estimated prevalence rate down to about 8% from a peak of close to 14% in the early 1990s; Thailand's "100% condom use" campaign among female sex workers has contributed to falling prevalence in military recruits and antenatal clinic patients.2 In the opening plenary session, Professor Roy Anderson (Director, Centre for the Epidemiology of Infectious Disease, Oxford) explained that interventions to interrupt the spread of HIV in populations would have relatively little impact once prevalence was high. Targeting individuals engaging in high risk behaviours was only effective early in an epidemic; unfortunately, few governments have been prepared to invest resources in the early stages, when such efforts are most cost-effective. There was hope that relatively inexpensive strategies to prevent heterosexual transmission of HIV might emerge from the conference. Unfortunately, the results of a study of a vaginal microbicide containing nonoxynol-9 among sex workers in Côte d'Ivoire showed a higher infection rate in the experimental arm. This suggests that the microbicide's detergent action caused ulceration that enhanced HIV transmissibility. Mother-to-child transmission Amid the gloom of the inexorable spread of HIV in Africa and emerging epidemics in Eastern Europe, delegates were virtually unanimous that there should be no delay in implementing cost-effective measures to prevent mother-to-child transmission of HIV, especially with some drug companies offering to provide free drugs in less developed countries. Data from a prospective observational study in the USA showed that, with optimal maternal combination antiretroviral treatment, the risk of mother-to-child transmission falls to as low as 1%. In breast feeding populations treated with only one drug the gains were less dramatic, but nevertheless very impressive, with the potential to prevent the infection of 25 000 infants a year in South Africa alone. Data presented at the conference reinforced concern that the benefit of perinatal antiviral therapy would be lost when mother-to-child transmission occurred during subsequent breast feeding. However, analysis of the HIVNET 012 trial (mother and infant each received a single dose of nevirapine in labour and by Day 3, respectively) at 18 months showed that an absolute 8% reduction persisted despite prolonged breast-feeding.3 These interventions prevent only about a third of mother-to-child transmission, but they point to cost-effective strategies relevant in resource-poor settings. Implementation will be challenging; it was clear that many women attending African antenatal clinics do not accept HIV screening, do not return for results or do not accept antiretrovirals if HIV positive; attrition rates of 80% were reported. The role of breast feeding in perinatal transmission of HIV was firmly established by a randomised, controlled trial in Nairobi, Kenya.4 While observational data suggested that exclusive breast feeding may be safer than mixed feeding, bottle feeding provides the best protection against HIV infection. The Nairobi investigators reported that the mode of feeding did not affect survival to 24 months, either in the infected or uninfected infants. Surprisingly, breast feeding was associated with three times as much maternal mortality at two years as formula feeding. Vaccines New candidate HIV vaccines presented at the conference provided some hope for the future control of the pandemic. After the disappointing immunogenicity of the recombinant protein vaccines, which were designed to elicit antibody responses, it was thought that strategies for eliciting cellular immunity, particularly cytotoxic T lymphocyte (CTL) activity, may be more successful. The trials of vCP205 (a canarypox virus expressing HIV genes), both alone or with a recombinant protein boost, showed very few vaccine recipients with detectable CTL activity, and these few responses were not sustained. However, it was shown that responses were detected more frequently when vaccine recipients received higher doses of vCP205, so more antigen expresssion may be necessary to achieve the desired levels of immunity. Results of a Phase II trial of the whole, killed HIV vaccine, Remune, in HIV-positive individuals in Thailand were presented. The subjects who received the therapeutic vaccine had a small but significant increase in the CD4+ cell count (P = 0.05) of about 46 cells/µL, with increased antibody levels but no change in viral load. Probably the most controversial decision relating to HIV vaccines in the past few years was to take the AIDSVAX recombinant envelope protein into Phase III clinical trials (in Phase I/II trials the vaccine did not induce antibodies that would neutralise circulating strains of HIV). It was reported in Durban that enrolment in the Phase III trials had been completed in Thailand (n = 2100) and the USA (n = 5400). Efficacy data will not be available until early 2003. There are many new vaccine concepts currently undergoing preclinical testing and some impressive data were presented on experiments in mice and macaques. Stephen Kent (Principal Research Fellow, HIV Vaccines Laboratory, University of Melbourne) presented further evidence that a prime-boost vaccine strategy using DNA vectors, followed by fowlpox virus recombinant for gag and pol simian immunodeficiency virus genes, produced very high levels of cellular immunity in macaques, and that these responses could be increased by the co-expression of the cytokine gene IFN-g. This candidate vaccination strategy, for which the University of New South Wales was recently awarded $27 million by the US National Institutes of Health (NIH), will be tested in Phase I/II human clinical trials in Australia within two years. Another vaccine that has generated considerable interest was presented by Dr Robert Johnson (Director, Alphavax, Professor of Virology, University of North Carolina). The vector for the vaccine, a Venezuelan equine encephalitis replicon, was shown to target dendritic cells, one of the most powerful inducers of cellular immune responses. Testing of this vaccine will begin in South Africa early next year. Dr B. Ensoli (Virologist, Instituto Superiore di Sanità, Rome) also presented some convincing data on preclinical macaque studies of a vaccine targeting immune responses to the tat gene of HIV. She found that five of seven macaques were protected from infection with pathogenic simian/human immunodeficiency virus challenge, and that these monkeys had developed good cellular immune responses to tat protein. Clinical trials are due to begin with this vaccine in Italy and Africa. Thus, although HIV vaccines tested to date have produced somewhat disappointing results, there was optimism at Durban that the next generation of vaccines are promising. Treatment strategies Clinicians and patients have recently become excited by the concept of structured treatment interruptions, which have been suggested to enhance immune responses to HIV while providing relief from the cost, inconvenience and toxicity of complex antiretroviral regimens. Dr Tony Fauci (Director, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland) presented a pilot study of five patients selected because they had achieved undetectable viral levels with potent therapy. They then interrupted therapy for one week in two. During seven such interruption cycles the patients' viral levels remained undetectable and their immune function was preserved. However, because the cohort was small, the subjects highly selected (with extremely well controlled viral replication) and the period of observation was too short, the results did not provide reassurance that such a strategy would not be associated with the risk of induction of drug-resistant variants. It is thus much too early to recommend this strategy in clinical practice. Hope Overall, the conference was hugely successful. Despite talk of boycotts because of Mbeki's views, the conference was well attended. The colourful national costumes of delegates, signage, art and craft displays and street theatre all provided a celebratory atmosphere. There was a mood of optimism that the problems of access to treatments in resource-poor countries were at last beginning to be addressed. Simple, cost-effective, population-based prevention strategies are working in those countries which have implemented them. The hope is that an affordable preventive vaccine that is active against strains of HIV in areas of high prevalence is not too far off. References Closing address by former President Nelson Mandela at the 13th International AIDS Conference, 14 July 2000, Durban. <http://www.aids2000.com/> Accessed 1 November 2000. UNAIDS. Report on the global HIV/AIDS epidemic, June 2000.<http://www.unaids.org/epidemic_update/report/index.html> Accessed 1 November 2000. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354: 795-802. Nduati R, John G, Mbori-Ngacha D, et al. Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA 2000; 283: 1167-1174. Authors' details Department of Immunology, Sydney Children's Hospital, Sydney, NSW. John B Ziegler, MD, FRACP, Associate Professor. Rosemary A Ffrench, PhD, Senior Scientist, Research Laboratory. Reprints will not be available from the authors. Correspondence: Associate Professor J B Ziegler, Department of Immunology, Sydney Children's Hospital, High Street, Randwick, NSW 2031. j.zieglerATunsw.edu.au 1: Seroprevalence of HIV in African countries in 1999 Over the last decade HIV has spread dramatically in sub-Saharan Africa, the fastest increases in prevalence occurring in Eastern and Southern Africa. (Reproduced by kind permission of the Joint United Nations Progamme on HIV [UNAIDS].) Back to text 2: Trends in mortality among children under five years old, with reference to adult HIV prevalence rate at the end of 1999 During the 1980s there were impressive improvements in child mortality attributable at least in part to improved immunisation rates, better management of diarrhoeal and respiratory disease and economic development. However, those gains are being lost and the increased child mortality rates are attributable to increasing incidence of perinatally acquired HIV. (Source: Demographic and Health Surveys, Macro Intenational, USA.) Back to text 3: Probability of a Zimbabwean boy aged 15 years dying before age 50 Trends are shown according to data from various national surveys. In high prevalance countries, a teenager has a greater than 50% chance of dying of AIDS before age 50. (Source: Feeney G, unpublished data, 1999.) Back to text 4: Projected population structure with and without the AIDS epidemic, Botswana 2020 The population chimney graph shows the dramatic impact that AIDS is predicted to have on the structure of the population of Botswana, where over a third of the 775 000 adults are now infected with HIV. The red pyramid shows the population structure as it would be in the absence of an AIDS epidemic. More children would be born (because more mothers would survive and remain fertile throughout their reproductive years) and fewer would have died because they acquired the virus from their mothers. Far fewer young adults would die before old age. The yellow areas show that the burden of AIDS will be greatest in children and in the most economically productive years of adult life. The implications of this change in population structure are shocking. The United States Census Bureau projects that in 20 years' time there will be more adults in their 60s and 70s in Botswana than in their 40s and 50s. This is based on the assumption that patterns of new infection will not change greatly over the next decade; however, as changes in future infection rates will principally affect men and women under 40 in 2020, the demographic chimney pattern for older adults is hardly affected by this assumption. The "missing adults" -- men and women who should have reached their 40s and 50s in 2020 -- are now in their 20s and 30s, although some have already died. Many more are already infected with HIV and will die before they reach their 50s.2 (Source: US Census Bureau, World Population Profile 2000.) Back to text

John B Ziegler · Rosemary A Ffrench

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